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� . � � Sec.13.04 RIGHTS OF SUBJECTS OF D�,T� Subd. 1. Type of data. The riehcs of individual on whom the data is sto[�d or to be stored shall be as se[forth in this secdon. Subd.Z. Information required to be�ven individual. An individual asked to supply priva[e or conhdendal data concerning himself shall be informed of: (a) the purpose and intendzd use o[the requested data wi[hin che collecnng"state agency, polidcal subdivision, or statEwide syscem; (b)whether he may reiuse or is le2ally required to supply che:�quested dara;(c)any lrnown consequence arising from his supplying or refusing to supply pciva[e or confidendal data:and(d)the idendcy of o�her persons or endnes authorized by sta[e or federal law to receive the data. This requirement shall not apply when an individual is asked to supply invesn�anve data. pursuan[to secdon 13.82, subdivision�, to a law enforcement officer. The commissioner of revenue mav olace �7e r.00ce reauired under this subdivision in the individual iacome [az or oronem taz retund instructions instead of on rhose forms. Subd. 3. :�ecess to data by individual. Upon requesc to a responsible auehoriry,an individual shall be informed whecher he is the subject oi stored data on individuals, and whether it is classified as puolic, pnva�e or contidenaal. lipon his further request, an individual who is the subject of stored private or pubiic data on individuals shall be shown [he data wi[houc any charge to hun and, ii he desires, shall be informed of the content and meaning oT thac data. :�fter an individual has been shown rhe priva�e data and informed of ia meaning, che data need not be disclosed to him for six months chereafter unless a dispute or action pursuant to this secnon is pending or addidonal data on the individual has been collected or created. The responsible au[horiry shall provide copies o[rhe privace or public data upon request by the individual subject oi[he data. The responsible auchoriry may require the requesring person ro pay the actual costs of making, cemfying, and compiling [he copies. The responsible authoriry shall comply immedia[eiy, if possible, with any request made pursuant to this subdivision, or wi[hin five days of the date of the reques[, excluding Sa[urdays.Sundays and 1e2a1 holidays, if immediate compliance is no[possible. If he cannoc comply with the reques[ within that time,he shall so inform che individual,and may have an addidonal five days wichin which to compty with the request,excluding Sa[urdays, Sundays and legal hofidays. Subd.4. Procedure when data is not accurate or complete. An individual may con[est[he accuracy or completeness of public or private data concerning himseff. To exercise this rieh[,an individual shall nonfy in writing the responsible au[horiry describing the nacure of the disagreemenc. The responsible auchonry shall within?0 days either. (a)correct the data found ro be inaccurate or incomplece and attempt to notify past recipients of inaccurate or incomplere data, inciudine recipien[s named by the individual; or(b) nod'ry the individual tha[he believes the data to be correc[. Data in dispute shall be disclosed only if the individual's statemenc of disagreement is included wi�h the disdosed data. The de�ermina[ion of the responsible authoriry may be appealed pursuanc to the provisions of the admirustradve procedure act relating co contested cases. DAT� PRIVACY ADVISORY In accordance with M.S. 1�.04, Subd. �, "Rights of subjects of data", we would like to inform you that your request for a permit or license from the City of Orono or any of its departments may require you to furnish certain private or confidential information. :ou �;e :ociried :hat: 1, The information you fumish will be used to de[ermine your qualification for the permit or license requested. 2 You may refuse to supply data, but refusal may require that the City deny the permit or license. 3, The information may be shared wich o�her local, state or Tederal agencies to the extent necessary to process the permit or license. 4. If your requested permit or license requires Council action to approve, some information may become public. 5. You have certain rights under �I.S. 13.04 (available upon request) to review private data on yourself. 6, Your full name is required to process this application or permit. �"�fi/C _,L�1S�D�,�J�1( �- ,%��S D�i�,/,t/� Firsc `iiddle Las[ .��/��_ S�/�-p�G�J��/� /�L�. Address �� �_�`� �' i�� f � -s - City Sta[e Zip Phone I underst my ts as�ted above. ;; �� ,/� - J Signature